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r %woe <br /> MONTfORLNG WELL.INSTALLATION REF--e-T <br /> `t <br /> $ - Z-T; <br /> qJ ms Z 8 ZO O Z CONSTRUCTION <br /> Date. _ L i <br /> �rcQll�aK.Z Total DepthS <br /> ,?remise Address: Screen Length (from) (LO}Z - <br /> ,A�,At (from) <br /> Filter Pack <br /> Well No.: 1vL� �,��—J Bentonite (from) <br /> .} D N Grout (from) (to) <br /> inspector. Drilling rig type <br /> /L� 3 Auger OD. I.O. <br /> Permit No. Completion - Stove pipe/csuistie box (circle one) <br /> an <br /> Drilling Com F Y <br /> cas Lag <br /> Driller. F[r717 � ' ght t <br /> l / i` ' <br /> Consuitant_ —W' UV—i+f <br /> Geologist ASOYE-GRCUNO ifs^01-3cx ' <br /> C�urx�5txfacs <br /> SPECIAL PERMIT INFO. _ <br /> Distance to sewer line <br /> Domestic well on site - ( y/ n) - <br /> If yes, location and distance - � f- <br /> h �- <br /> 3 �• <br /> S„SNC* <br /> Holding Temperature 3 _ 72"1 pack <br /> Method— <br /> Screening Method <br /> Tracking Sheet y n} <br /> —..�tt. ♦ L-- It <br /> ML <br /> SPOILS ! <br /> [ MATERIALS/DEVELOPINENT <br /> Storage Method <br /> + <br /> Contamination Noted - C y/ n} Qr ✓ <br /> Casing type v L <br /> Storage Location --?—tartfr- <br /> Lit Blank fr- Screen <br /> Slot sue d <br /> GROUPING ,L 00 � 3Bags cement <br /> ST Buckets bentonite <br /> �L71 b5� y,� r�V�%W�� Bags sand/gravel <br /> ll Dep to water-423- Filter Pack type/siz <br /> Mix Ratios Surge Block: - (y a <br /> Installation Method Discussed with geologist; - C Y <br /> Quantity Installed Type of method <br /> EH 29 29 <br />